Provider Demographics
NPI:1831703867
Name:SULLIVAN, HENRIETTA LYNN
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 BILLY DOTSON BR
Mailing Address - Street 2:
Mailing Address - City:PHELPS
Mailing Address - State:KY
Mailing Address - Zip Code:41553-8514
Mailing Address - Country:US
Mailing Address - Phone:606-369-0235
Mailing Address - Fax:
Practice Address - Street 1:167 BILLY DOTSON BR
Practice Address - Street 2:
Practice Address - City:PHELPS
Practice Address - State:KY
Practice Address - Zip Code:41553-8514
Practice Address - Country:US
Practice Address - Phone:606-369-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant